Plastic Lessons

I always feel awkward when I talk to plastic patients. The simulation mannequins are impressive: their eyes blink, their chests expand as they breathe, they have pulses, they bleed, they burn. A screen monitors vital signs: I administer a pressor and a dipping blood pressure perks up, or I order a beta blocker and a racing heart rate slows. A physician in the next room lends her voice to play the patient, responding to what I do and say. A physician in the same room becomes a tech, relaying results of my tests and nudging me through the next steps when I veer off course.

The situations are designed to be overwhelming. I look helplessly at the “tech” when he asks me how many liters of saline I want to give the patient. When the patient asks what’s happening or when fear enters her voice, I give automated reassurances while my mind wanders through differentials. When the patient begins deteriorating for reasons beyond my comprehension, I pause for too long: listening to the beeping of the monitor, watching her oxygen saturation plummet, and waiting for the scenario to be over so I can be rescued. During simulations, the student usually needs as much rescuing as the patient.

That morning’s mannequin was distraught. She was bleeding profusely from her vagina and was terrified that she was miscarrying. Her blood pressure dropped. She wouldn’t stop crying. She was asking a lot of questions. The tech wanted to know what he should tell her boyfriend outside. I used about 5% of my mental capacity in an attempt to soothe her and deflect her boyfriend’s worries. The rest I reserved for piecing together the tiny bits of information I had gleaned so far on my ob/gyn rotation on how to diagnose and manage miscarriages. I stabilized her blood pressure and admitted her for surgery, but she was still crying as the scenario ended. In my eyes this was success.

Excited to get away from plastic people, I re-joined my team on the floor that afternoon. I found our next patient in the surgical waiting area. She had had a miscarriage.

There are eight beds in the waiting area, each separated by a few feet and three quarters of a curtain. In a span of twenty minutes, the patient meets a slew of personnel: surgeons who explain what recovery will look like, anesthesiologists who verify medications and allergies, nurses who update physicians on the patient’s recent changes, and translators when necessary. The room is busy but not chaotic; animated but not loud.

And there my patient sat, crying in her bed.

Everyone around me had a task. Each person gave the patient words of sympathy–which eerily echoed mine from only a few hours before–and moved on to the next aspects of her care.

Although I was technically part of the surgical team, I was also technically useless at that point. Unlike simulations during which I had to balance medical management with verbal comfort, this time I could allocate my entire brain to the latter.

I only wished it were merely as uncomfortable as it was with my plastic patient.

After introducing myself and uttering the requisite situational apology, my face molded itself into an expression of glum empathy. I was amazed by the nurses’ facileness in switching their expressions as they moved from bed to bed. Within my patient’s fifty square feet, they held her hand and lowered their voices. Then, with their backs turned and sixty seconds behind them, they bantered with the next patient. The physicians busied themselves writing notes, looking up records, and explaining to the patient what dilation and curettage meant.

With nothing to do but nowhere else to be, I stood silently by the patient’s bedside, unwilling to interrupt the medicine taking place, even when the medicine wasn’t being spoken aloud. I was convinced that she perceived me as some sort of creepy extra during one of the worst days of her life. But still, I didn’t speak. I knew she’d remember a stupid or hurtful comment more vividly than no comment at all.

She seemed to sense that her doctors considered her impending procedure relatively short and safe. (At twenty minutes and only somewhat invasive, it was.) Through her tears, she tried to justify her questions. “I know you do these things every day, but for me it’s new and I’m terrified.”

I desperately wanted to tell her that I wasn’t like the rest of them. It was new for me too. Just as she would always remember this surgery, so would I. But I remembered my superiors’ advice (approaching an order) not to let on to patients how inexperienced I was.

I needed her to know. As she looked more miserable, my judgment waned. During a lull in the preparations, I very quietly said to her, “I’m not going to do anything at all during the surgery; I’m only watching. But it’s my first time too.”

“First time? Join the club,” she repeated, too loudly. I knew my intern had overheard. I could only hope that she wouldn’t be the one writing my evaluation.

Did I have anything at all to offer? “I’m just a student so I won’t know all the answers to your medical questions. But I have a lot more time than these guys”–I gestured with my head to the rest of the team–“which means I have a lot more time to help you in any way I can. If you need anything, please let me know and I’ll try to get it for you.”

She nodded, and I realized I had finally found my place. It wasn’t big–about fifty square feet. In fact, it was precisely the size of my patient’s world. A bed. A curtain. An IV line and a monitor. People who faded in and out of their own ever-shifting worlds. A patient and her mother. And me.

I thought back to the simulation of a few hours ago. It was useful, but not immediately so. With plastic patients, I am learning how to be a doctor and feeling overwhelmed with medicine. With real patients, I am on the cusp of learning how to be a doctor-in-training and feeling underwhelmed with myself. At some undetermined time, I hope the two paths will find a way to meet.

As we wheeled her bed out of the holding room and toward the operating room, her mother asked how long before she could see her daughter again. I was the only one who heard. Frustrated, I couldn’t even answer that. I nudged my intern and repeated the question.

Hi Shara, i just was sent a link to your blog. I am sure you know, the gift of time and attention is sometimes more valuable than our medical knowledge or technical prowess. To quote (or mis quote) Georgia O’Keefe, ” a flower is so small, to see a flower takes time, like to be a friend takes time”. I’m glad you see the small flowers.

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About This May Hurt a Bit

Shara Yurkiewicz is a first year resident at Overlook Medical Center in New Jersey. She is training to be a doctor in physical medicine and rehabilitation (PM&R). Her residency is broken into two chapters: Year one in internal medicine at Overlook Medical Center, followed by years two through four at Stanford for PM&R. She received her MD from Harvard and her BS from Yale. She was an AAAS Mass Media Fellow and has written for the LA Times, Discover, and MedPage Today.